COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

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FIED PROGRAM CONSOLIDATED FORM4W ( 1,1 o TANK: 7A0515595 PR#: PR0231866 UNDERGROUND STORAGE TANKS - TANK VLVF-FAC#: FA0003957 (two pages per tank) (fes TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑4 AMENDED PERMIT [j5 CHANGE OF INFORMATION E] Page2of3 6 TEMPORARY SITE CLOSURE .� (Check only item only) .p",, .,,�,--" �'p• ?n„ ,. . it ,,M,t > ❑ 7 PERMANENTLY CLOSED ON SIO ❑ 3 RENEWAL PERMIT ( y5'reasoo� �, (SP«nY�On ) y" ❑8 TANK REMOVED 43 BUSINESS NAME(Same as FACILITY NAME or DBA-[Ming Business As) FACILITY ID: PR#: a PACIFIC BELL 3 FA0003957 PR0231866 [Tj �\ LOCATION WITHIN SITE(optional) 124 W ELM ST,LODI 431 PHONE I.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# Tank#: 4 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0515595 MODERN WELDING If"Yes".complete one page foreachcompartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 8,000 ADDITIONAL DESCRIPTION(For kcal use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ I a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (1 f marked complete Petroleum Type) ❑ Ib.PREMIUM UNLEADED ® 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT 4.HAZARDOUS WASTE COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑ (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one item only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS p 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Check one item only) ❑ 2.STAINLESS STEEL ®4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING (Check one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ❑ 6 UNLINED ❑ 99.OTHER (For total use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item only) ❑ 4 IMPRESSED CURRENT E] 99 OTHER ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ® I SPILL CONTAINMENT 2,001.00 ® I ALARM ® 3 FILL TUBE SHUT OFF VAL` ❑x 2 DROP TUBE 2,001.00 ❑ 2 BALL ❑ 4 EXEMPT ❑X 3 STRIKER PLATE 2,001.00 FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the 1=1 agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) a55 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 7/25/2001 0.00 gallons ❑Yes ❑No UPCF(12/99 revised)